Healthcare Provider Details

I. General information

NPI: 1790602845
Provider Name (Legal Business Name): CENAAN KELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E 4TH AVE
SAN MATEO CA
94401-4001
US

IV. Provider business mailing address

342 41ST AVE
SAN MATEO CA
94403-4306
US

V. Phone/Fax

Practice location:
  • Phone: 707-623-4556
  • Fax:
Mailing address:
  • Phone: 707-623-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: